Hill Burton

The Hill-Burton Act

There are a few events in the 20th century that can compare to its ability to conjure fear and foreboding in the minds of American citizens than the “Great Depression” of the 1930s. Its effect could not be fully described and its consequences too could not be quantified. Suffice it to say that many learned their lessons. The event, the principles learned and the causes leading to it became some sort of a reference point for the government and businesses from which they will measure current trends and developments in order to prevent another crash. The economic downturn calls for some serious change in governance, legislation and attitudes. Adjustments were made alright; but these modifications in how the US conduct business did not only focus on the things that would make money i.e. traditional industries. It is quite surprising to know that sweeping changes were made and this has impacted the healthcare sector as well.

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The Hill-Burton Act is the most prominent piece of legislature that could be considered as the most recognizable evidence of what the government tried to do with America’s healthcare system just after the crisis of the 1930s. This legislative action was not perfect but it was a precedent that at best provided a model for future developments in related services and at worst is the catalyst for change.

The legacy of the Hill-Burton Act is still felt today. A number of modifications were made since its inception but the spirit of the original law is still apparent as it was first seen decades earlier.

In the following pages, the Hill-Burton Act will be studied more carefully from the beginning up to the present. Moreover, a more in-depth look on the circumstances leading to its creation will be included to provide a better understanding to what it meant to the US healthcare system. In the Beginning

The website of HRSA under the US Department of Health and Humans Services ascribes two major events that lead to the creation of the Hill-Burton Act. The first one was the aforementioned economic downturn of the 1930's. The second major event that indirectly led to its legislation is World War II.

In the same website one can find a more detailed description of said law:

In 1946, Congress passed P. L. 79-725, the Hospital Survey and Construction Act, sponsored by Senators Lister Hill and Harold Burton and widely known as the Hill-Burton Act. It was designed to provide Federal grants to modernize hospitals that had become obsolete due to lack of capital investment throughout the period of the “Great Depression and World War II (1929-1945). Hill-Burton were required to provide uncompensated services for 20 years after receiving funds. (see HRSA).

That in a nutshell is Hill-Burton Act and also what was stated above were the general circumstances that led to its legislation. The Hill-Burton Act was created not in a vacuum but there were forces that triggered its inception. With this line of thought, Thomas Weil offers a more in-depth analysis how the Hospital Survey and Construction Act came to be. Weil traced back its beginnings in a regional and comprehensive Health care planning trend in the United Stats that began as early as 1929. In that same year a working committee was formed which was aptly named the Committee on the Costs of Medical Care. Again, Weil explains:

Supported by one million dollars from six foundations, the committee and its staff studied the incidence of disease and disability in the United States, how to improve the integration of Health care facilities and services, the relationships of family income and the receipt of health service and the income earned by the health providers. (Weil, p.18).

From the complex data gathered by the committee it was understandable that there will be a lack of general consensus when the time came for offering recommendations. Yet at the core of the recommendation is a call for a better way of financing and organizing Health care services. The first major attempt to translate what CCMC (Committee on the Costs of Medical Care) – aspired for in theory – into action was the creation of the Hill-Burton Act.

Weil described the simple approach to the complicated problem presented by CCMC, “The purpose of the act was to enhance acute services on the basis of hospital bet-to-population ratios and to build newer facilities. Because of the Depression and later World War II, only modest hospital renovation or expansion had occurred during the prior 15 years” (p. 20).

The work of the lawmakers, Hill and Burton did not go in vain. The law they co-authored took flight and made changes on many states. Weil describes the initial impact of the act at least on a statewide basis:

The Hill-Burton program provided federal grant assistance to the states for surveying their health needs, and, based on these findings, they were able to develop priorities for hospital facility construction. With well-documented plans for expanding facilities, and with minimum standards for hospitals incorporated into state licensing laws, federal funds were made available on a priority basis, and the monies were matched up to one-third of the total project cost to construct and equip...(p.20)

Early Critics

Steven Jonas, in his book Introduction to the US Health care remarked on the inherent weakness of the said law:

The Hill-Burton Act was limited however; in it was a state-based rather than a comprehensive approach to remedying Health care inadequacies. It focused overwhelmingly on beds rather than services that might or might not require additional beds. (p. 141)

Gottlieb in 1974, made the following observations, “There was little provider-consumer interaction in the program, nor was there much interaction between Hill-Burton activities and other health planning efforts”(qtd. in Jonas, p.141).

In the area of physician redistribution Clark and Koontz in 1973 remarked that “...because its approach to physician redistribution was all carrot and no stick, its results in that area were less exemplary” (qtd. in Jonas, p. 141).

Early Success

But it was not all downhill for the proponent of the law and for the legislation itself, as of 1970 it can boast a modest string of achievements, Joans wrote the follwing:

By 1970, the program had assisted in the construction of facilites housing 334,438 hospital beds and 93,749 long-term care beds, as well as 1,032 outpatients facilities, 520 rehabilitation facilities, 1,258 public health centers, and 41 state health laboratories. (p.141)

Amendments

The law was passed right after the end of the Second World War. The world and America changed dramatically since then. There is of course the need for changes in the law itself. The HRSA website provided the information on the amendments made in 1975:

Title XVI of the Public Health and Service Act [...] Title XVI transferred the enforcement responsibilities from States to the Federal government, and required more stringent investigation, monitoring and compliance standards. The Act also empowers the government to recover grant funds in certain situations when the facility is sold, transferred to an ineligible entity, or ceases to be used for an eligible purpose within the 20-year obligation period. (see HRSA)

Legacy

The impact of the Hill-Burton Act was summarized by the HRSA in the following statements:

$4.6 billion total grants and $1.5 billion total loans between 1946 and 1997

6,800 health care facilities in more than 4,000 U.S. communities

In the website of the United States Department of Health and Human Services, the following information was posted:

The Community Service Assurance under the Title VI of the Public Health Service Act requires recipients of Hill-Burton funds to make services provided by the facility available to persons residing in the facility’s service area without discrimination on the bases of race, color, national origin, creed, or any other ground unrelated to the individual’s need for the service or the availability of the needed service in the facility. These requirements also apply to persons employed in the service are of the facility… (see USHHS).

On a separate document from the US Department of Health the public was made aware of the existence of a means for low cost healthcare. In the document instructions were made to on what management of such facilities must do to comply with the law and it states, “Hill-Burton facilities must post a sign that says “NOTICE-Medical Care for those Who Cannot Afford to Pay” (see USHHSA). And this is what makes America a great country.

Conclusions

The Hill-Burton Act was not created in a vacuum. There were events and forces that shaped its destiny. But it was the work of two lawmen, Senator Lister Hill of Alabama and Representative Richard Burton of Michigan that paved a way for the creation of a successful model that can be used as benchmark for future forays into re-engineering of the US healthcare system.

The Hill-Burton Act is not without its faults. In the words of Weil, “It focused on institutional rather than comprehensive, regional approaches to remedy health delivery system inadequacies. Its overwhelming emphasis on reducing acute care bed scarcity indicated the absence of a broader goal-setting process rooted in identified community needs” (p.20).

But viewed another way the Hill-Burton Act had assisted a significant number of patients whose lives would have been in danger had it not been for this law. It also trail blazed a path for others to follow.